Prolonged Exposure: A first-line treatment for PTSD

In 2006, VA began a national training initiative to help VA clinicians learn two of the most effective types of psychotherapy for treating PTSD, Prolonged Exposure and Cognitive Processing Therapy. Today over 6,000 VA therapists have been trained in these treatments. These therapies are recommended as first-line treatments in all PTSD practice guidelines around the world, including the guideline jointly issued by VA and the Department of Defense. VA requires that all Veterans have access to these treatments, and for good reason. They are effective for Veterans and non-Veterans alike.

Recent concerns raised about Prolonged Exposure therapy and VA wait times for PTSD treatment may deter some Veterans from seeking care that can help them. We regret that any Veteran seeking help at VA has a negative experience. VA seeks to ensure that high quality, timely health care is delivered to every Veteran who needs it. We maintain that this effort is well underway and continues to gain momentum.

Access to care is one of VA’s top priorities for improving Veteran services. Secretary Bob McDonald has re-emphasized this focus on access with the bottom line being Veteran satisfaction (instead of an “average” wait time number that is vulnerable to manipulation). MyVA is the name for this energized internal realignment that will enable all VA services to be viewed and judged through the eyes of the Veteran.

In Prolonged Exposure, patients retell an account of a traumatic experience repeatedly in order to fully process their memory of the experience, which makes it less painful and something that no longer dominates their life. They also are asked to engage in homework listening to a recording of their account, and to visit places that are safe, but which they may have avoided because they are related to their traumatic experience, for example, a crowded shopping center or driving down the street on trash day. VA strives to accurately describe the clinical services we offer, using standardized information sources such as websites, printed materials and prepared verbal explanations. At the outset of Prolonged Exposure, patients are informed that the focus on a traumatic memory may cause a temporary increase in PTSD symptoms. The workbook for therapy says, “You may feel worse before you feel better,” but that this temporary increase is worthwhile.

It is. Most Veterans who receive Prolonged Exposure experience a decrease in PTSD in 10-12 sessions. For example, a study published in 2013 of outcomes for Veterans who received Prolonged Exposure from VA in the national training initiative found that over 60% of the Veterans experienced clinically meaningful improvement in their PTSD symptoms despite the fact that the clinicians were just learning the protocol. An earlier study of women Veterans in 2007 found that over 70 percent experienced clinically meaningful improvement after receiving Prolonged Exposure. Cognitive Processing Therapy is another treatment approach that results in similar levels of improvement. Veterans who are not helped by one treatment are encouraged to try others.

VA’s aim is, and will continue to be, to offer Veterans an increasingly broad range of effective treatment options for PTSD and other conditions. Veterans have a choice of treatments. Along with Prolonged Exposure, Cognitive Processing Therapy, other types of psychotherapy, and medication, VA also offers complementary and alternative therapies such as meditation to allow Veterans a choice of treatment options and help them achieve recovery.

But there is still much to learn, and there are many improvements to make. We welcome feedback from all of our partners —Veterans and their families, treatment professionals, researchers, advocacy groups, and more. Working together, we can help VA accomplish the mission originally described by President Lincoln: “to care for him who shall have borne the battle and for his widow, and his orphan.”

I am in a program called HORSES WITH HEART. Working with the horses& helping handicapped kids has helped me cope with PTSD more than any medications they have given me. When I’m on my horse, everything else disappears; no pain, no bad thoughts, NOTHING else exists. The same goes while working with the kids. I can’t thank the VETERANS Administration enough for hooking me up with this program! PLEASE MAKE IT AVAILABLE TO MORE VETERANS. And I’m not even a red neck!

To repeat something over and over is how you form a habit. There ia another program hoofsandboots.org that works with Wounded Warrors that I have referred patients to (no, I am not working psych). It has been proven that even brushing a horse will lower the b/p for both. I have 13 horses just outside of Ft Lee Va. and vets frequently come by wanting to buy a horse because of fond memories or just want to be around them evenn if they don’t ride. I would love to get involved with Wounded Warriors as I have the resources, just not a contact. Why repeat a bad experience over and over when you could replace it with thoughts of all the fun a horse can be. It hase helped my own non-combat PTSD where the repeating bad memories did not help my older daughter at all . She quit seeking help and it shows. I can laught at my horses, feel their soft noses, they don’t judge if I cry, they never make a plan of care, they never repeat anything I say, and families can be involved. After all that’s who they went to protect-families. Hopw this helps someone out there

While many experience peace during the activities (mine was surfing) you can’t be on a horse, or in the water all the time. For many these are only temporary escapes from the thoughts that keep occurring in your head. I also have 5 dogs that are my therapy, but as you can see by the number of dogs it’s not enough. They help, but the PTSD is still there,

What CPT does is something else. It helps you process the trauma, that you never could alone. Instead of being “stuck”, it is a way to become more aware of yourself and your thoughts in relation to your trauma. I haven’t finished yet but I am hopeful. And it’s not easy. I am exhausted emotionally after each session. I had to drop out, due to illness but hope to return and complete the process.

VA to date has been good to me. I realize that the numbers of patients seeking care is crushing, yet I feel they are concerned on an individual level, Thank God. I seek out the VA for care because I am amongst my brothers, we have common backgrounds, shared feelings, emotions, concerns and the illness that go with our years. We understand each other, I need their company; we all need(ed) the help of each other…then and today. I don’t mind waiting because ‘my brother’ needs it more than I do

your above program on ptsd sucks wind because you have comingled combat with noncombat thus water down success of each or both,,,,, if you are going to deal with ptsd at least make a standard therapy for non combatants and give them all to one therapists via email or the like,,,,,, but for the combatants, the real ptsd, you ought follow my prior suggestion to put them all, all in one facility, into one group, housed as a group, in house or outpatient, all on 5mg compazine ad lib or prn, and use the only
therapy that will work, Rogerian therapy where the injured gropes until he re-finds his self and then enlargen that capacity into real world skills
this is to say your above therapy is chickenpoo without any insight and without any hope of success

Dear Bob,
I’m sorry you’re struggling so badly. PE and CPT are not for everyone. I also want to say that I disagree with your statement that “combatants” are the only ones that have real PTSD. By stating that you are saying that you don’t recognize all the suffering that victims of rape, holocaust survivors, POWs, etc have gone through. They also have real PTSD. You are also dismissing the millions of children who are abused, enslaved, and/or prostituted who also have very real and severe PTSD. I wish you peace and hope you find the right treatment.

I was just thinking along the same lines today as I was forming a reply. … I have PPTSD. That’s where you’ve crossed over to the other side of ptsd. I was going to explain that I’ve had no choice but to be fully exposed to it for years. When new fears or issues arise I have no qualms about heading straight back to keep forging my way through them because avoidance for me is a sucker bet. It’s not about being brave or extra smart, it’s about developing your senses realistically instead of through opinions or comfort. I guess I could also call it functioning ptsd… I never got a chance to express that and here I am. The best way is patiently through, and again. Thank you.

Reliving your trauma is the worst thing you can do…..the more you relive it, the more real it becomes….the nightmares get worse….the more isolated you become. I venture to guess the vets who are benefiting from this form of therapy are also on antidepressants/antipsychotics/antianxiety, etc., etc., etc. drugs. You can’t block out…..drug out…….alcohol out…..talk out the trauma—–it is forever imprinted in your brain. You can’t possibly understand PTSD until you experience the fear of having to deal with the possibility of death at the hands of another human being. THANKS FOR LISTENING….

wouldn’t you know it, as soon as I put this comment (in a bad choice of places) they changed the code format. Now if you notice they have capitalized and lowercase letters in the code box. Maybe that’ll make it easier for us.

Totally disagree with this article. This so called Prolonged Exposure will not cure the patient 100%. I also disagree that PTSD goes away. Sorry folks, but you try having a trauma and expect that your life will be better, a person is never the same. I expect that the article here will lead to more poor diagnoses. Articles like this cause doctors, psychiatrists and PhD’s to jump on the bandwagon and start another trend. Wrong, wrong, wrong.

I found it helpful when I heard someone consider the difference between ‘treating PTSD’ and ‘healing from trauma’. They are related, but not identical. The treatments such as PE, CPT, EMDR can be effective at treating PTSD, meaning reducing the intensity, duration, and frequency of specific symptoms such as nightmares and intrusive memories. This is truly helpfu for many people, and increases quality of life. However, the individual may still be profoundly effected by their traumatic experience(s), and may need to explore other therapeutic avenues to address spiritual, existential, and interpersonal struggles. Whatever the journey includes, I hope that having a variety of choices will help people take steps on a path toward healing and reclaiming their lives.

I can almost see the generational gap in the writings here. We old guys didn’t have the type of help the post-9-11 (01) vets have. I didn’t go to Vietnam; I was just a bit too young. There were 2 “conflicts” shortly after that though. YOUNG VETS please listen. When our brothers came home from over there, the battle didn’t end.They were spit on by the very people they had defended; called baby killers, denied help by the same gov’t that ORDERED them to go, etc. I am proud of you guys for volunteering, I did too. My point is simply that, the gov’t, including the VETERANS Admin, & American people have been so much better to post-9-11 vets, and YES you deserve to be treated well, but I & our older brothers have HAD to hold in our pain & deal with it however we could. Just know that I, for one, am thankful that you brave men and women did volunteer to serve this great country! Your sacrifices brought to light a problem that has been ignored by our corrupt gov’t for eons! THANK YOU!

The authors of this article shared the following response with the Vantage Point editors:

We want to thank everyone who has commented on this page. VA welcomes your feedback and criticisms so that we can continually improve our services to Veterans.

Effective treatments for PTSD exist. Veterans have a choice of treatments. There is no single road to recovery, and for that reason VA offers a range of treatments, including Prolonged Exposure Therapy and Cognitive Processing Therapy as well as Eye Movement Desensitization and Reprocessing (EMDR) and other treatment options. These treatments can be delivered individually (when a therapist meets with a Veteran one-on-one) or in a groups (when a therapist or therapists meet with several Veterans at once). Veterans with PTSD can also benefit from various medications. Many Veterans with PTSD, from those who served in Iraq and Afghanistan to those who served in Vietnam and Korea, have greatly benefitted from these treatments. Veterans understandably like to hear from other Veterans what their treatment experiences were like and you can do so at the Make the Connection website (http://maketheconnection.net/conditions/ptsd) or the About Face website (http://www.ptsd.va.gov/apps/AboutFace/). You can also get a quick take on PTSD and its treatment by watching these new animated whiteboard videos (http://www.ptsd.va.gov/public/materials/videos/whiteboards.asp).

VA also offers complementary and alternative—CAM—treatments such as mindfulness meditation, acupuncture, yoga, and others. Although the evidence on whether CAM is effective for treating PTSD is not conclusive, some Veterans may find that these kinds of treatments are useful additions to the treatments with proven efficacy.

VA has identified “recovery” as a guiding principle for its entire mental health service delivery system. Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life while striving to achieve his or her full potential. VA mental health providers are honored to play a part in Veterans’ journeys to recovery.

Please do not forget the families – the spouses that receive the blunt of the PTSD. They end up with their own cases of PTSD. Just recently the VA has developed the Caregiver’s site and has developed programs to come alongside the caregivers – which would be any spouse of a veteran that is suffering with PTSD. The world’s advice when a caregiver seeks help is to leave and not put up with the abuse. Fortunately, most caregiver’s are realizing that their vows were for better or worse, in sickness and in health! PTSD and TBI’s are mental illnesses. Can be hidden from the outside world but families do know! And it is horrible – horrible what it does to the veteran, horrible what it does to the spouse and even worse what it does to the children! Just as stroke patients go through therapy those with PTSD need more than pills and a visit to the doc every three months. Part of the treatment should be mandatory treatment!

Ok, welcome this: our corrupt gov’t takes millions in tax $$$$ from medicinal marijuana; when will they accept the fact that IT HELPS!!?? I don’t smoke because I don’t want to get busted, but let’s be honest – YOU KNOW IT WORKS.

I cut that last comment too short,I don’t use marijuana but I have in the past. If they don’t allow people, no since this is a veteran website, VETERANS access to medical marijuana, why not allow access to the edibles. Like I said, They take the tax dollars, that in itself should be a crime. Talk about a double standard!

Speaking of complementary and alternative therapy (CAM), there is compelling research evidence showing that the Mantram Repetition Program (MRP) reduces overall PTSD symptoms, and in particular, reduces hyper-arousal and avoidance. It has also shown significant reductions in insomnia. A mantram is a “sacred word” selected by the individual and is used to train attention and regulate emotions at any time or any place. Although similar to mindfulness meditation, it has several unique differences: 1) it welcomes spirituality and improves spiritual wellbeing, 2) it doesn’t require any set time or place to practice, 2) it has reportedly been effective in calming a variety of situations including road rage, anger, irritability, poor relationships, etc. It serves as a “pause button for the mind” to manage symptoms. Find out if this program is offered at your VA. Efforts are underway to make it more widely available.

It always amazes me that all these wonder folks who went to school and attended classes and read books about what some one else who did the same has figured out the secret to PTSD treatment. I am happy for those who have received help for PTSD and feel better. But in truth a real majority will agree to say anything to get these wonder folks to just leave them in peace. I agree, under certain conditions someone can maybe for a short time find some release from the symptoms, but for most the monster comes at night or when they are all alone and no wonder person is on hand . Soldiers suffering from PTSD can relate to others who have served under the same conditions but just “try” to get along with these wonder people so they will not say they are crazy. Nice try but way damn short. If it was that easy why does it just get worse with age and time

Mr. Durham, You nailed it Brother. PTSD is incurable, & those of us that are older & have had to hold it inside & deal with it however we could are probably “beyond repair”. Let’s be happy that our young brothers & sisters are getting better care for PTSD than we ever did.